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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801689
Report Date: 07/18/2025
Date Signed: 07/21/2025 03:05:07 PM

Document Has Been Signed on 07/21/2025 03:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLEDFACILITY NUMBER:
197801689
ADMINISTRATOR/
DIRECTOR:		TAMARU FRANCISFACILITY TYPE:
735
ADDRESS:715 E. CHESTER ROADTELEPHONE:
(626) 858-1803
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 6CENSUS: 6DATE:
07/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Tamaru (Nikki) Francis, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA arrived unannounced and met with the Administrator, Tamaru (Nikki) Francis and allowed the entry of the visit and assisted with today's visit. The purpose for the visit was explained. The facility is licensed and APPROVED FOR 6 AMBULATORY CLIENTS, AGES 18-59 and the facility is vendored as Level 4F with San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:



1. Infection Control: The facility has an Infection Control Plan in place and the facility continue to practice infection control with hand washing and disinfecting the facility. The facility has sufficient PPE supplies.

2. Physical Plant and Environmental Safety: The facility is a single-story house located in a residential neighborhood area. The facility includes a kitchen, dining area, living room, three clients bedrooms, two clients bathrooms and a detached garage. Each client's bedroom has two beds, two drawers, a nightstand, the required furniture and bedding and sufficient lighting and close space. The clients’ bathrooms are clean, sanitary and in good working conditions. Extra bed linens, sheets, pillowcases, and towels are located in the hallway cabinet. The hot water temperature in both bathrooms were tested between 114.9- and 115.3-degrees F which is within the Title 22 regulation. All the kitchen appliances are working properly. All the sharp knives and utensils are stored and locked in the kitchen cabinet. All the chemical and cleaning supplies are stored and locked in the cabinet near the entrance way. The extra personal hygiene are stored in the cabinet near the entrance way. Fire Extinguisher in the living room is fully charged and last inspected on 09/13/2024.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/21/2025 03:05 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/18/2025 at 11:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED
FACILITY NUMBER: 197801689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed Staff #1 (S1) and Staff #4 (S4's) file did not have a valid Health Screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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Administrator will send Staff #1 (S1) and Staff #4 (S4's) valid Health Screening to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED
FACILITY NUMBER: 197801689
VISIT DATE: 07/18/2025
NARRATIVE
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2. Physical Plant and Environmental Safety [Cont.]: There's a telephone service on the premises. The Hallway Light and automatic lights will be on during nighttime for clients to access the non-private bathrooms. LPA inspected the carbon monoxide detectors and it's working well. The fireplace is secure and inaccessible to clients. Outdoor patio has a shaded area for clients activities. The passageway, walkway and patio are free of obstruction.

3. Operational Requirement: The facility is approved for 6 ambulatory clients and currently all clients are ambulatory, which is within the fire clearance requirement. The clients can participate the community events if there's an opportunity. There are tables and chairs in the covered patio area for clients to utilize the outdoor activity. The last fire drill was conducted on 7/1/2025

4. Staffing: The facility has sufficient staffing. The night staff has the required emergency planned procedure training.

5. Personnel Records-Training: All staff files are stored and locked in the staff office. All the facility staff are over 18 years old, fingerprint cleared and associated with the facility. LPA reviewed five (5) staff files which include: health screening, TB test result, required training hours and updated first aid certificate. However, based on a record review, Staff #1 (S1) and Staff #4 (S4’s) file did not have a valid Health Screening in file. The administrator is Tamaru Francis and her administrator certificate is valid until 5/30/2026 and has the updated HIV and TB training certificate.

6. Client's right information: Currently no clients require any postural support. The facility has served internet services with at least one internet access device, so clients can communicate with their family or day program or physician.

8. Client's Records-Incident Reports: All the client's files are stored and locked in the staff office. LPA reviewed five (5) client's files which include: face sheet, physician report with TB test result and ambulatory status, admission agreement, functional capacity assessment, Individual program Plan (IPP), and Appraisal/Needs and Services Plan.

9. Health Related Services: The facility will assist clients with their medical and dental appointments with transportation too. LPA reviewed all six (6) clients’ medications and all medications are centrally stored in the kitchen cabinet and they all seem updated and accurate and they all have 30 days’ supply for medication. All six (6) clients have a Centrally Stored Medication Destruction Record in file. LPA reviewed the first aid kits which included all required items.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FIRST CHANCE FOR THE DEVELOPMENTALLY DISABLED
FACILITY NUMBER: 197801689
VISIT DATE: 07/18/2025
NARRATIVE
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10. Incidental Medical Services: No client in the facility has any restricted health condition or prohibited health condition.

11. Disaster Preparedness: The facility has an updated emergency disaster plan. The facility has at least two shelter location in place. The facility conducted fire/disaster drill on 07/01/2025.

12. Emergency Intervention. The facility does not use any restraints or seclusion.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to administrator Tamaru (Nikki) Francis

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
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